Provider Demographics
NPI:1396744967
Name:TESALONA, MARY ANN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:TESALONA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2146 VINDALE RD
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5602
Mailing Address - Country:US
Mailing Address - Phone:352-742-1715
Mailing Address - Fax:
Practice Address - Street 1:2146 VINDALE RD
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5602
Practice Address - Country:US
Practice Address - Phone:352-742-1715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0063400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371959600Medicaid
FL18442OtherBLUE CROSS & BLUE SHIELD
FL18442OtherBLUE CROSS & BLUE SHIELD
FLF50068Medicare UPIN